Page 13 - Duke Austin Ebook July 2017

DACO051 • June 2017
EMERGENCY PROCEDURE

NON-CONFORMITY, ACCIDENT OR NEAR MISS REPORT
In the event of an Non-conformity Accident or Near miss Duke Austin & Co should be informed as soon as
is practicable and this report should be completed and submitted to us within 24hrs to admin@dukeaustin.com
This form can be replaced by a copy of any similar report form that has been completed by a Qualified Person at
the point of accident/incident but should still be submitted within 24hrs.

Personal Details Witness or persons reported to

Name: Name:

Address: Address:

Email: Email:

Signature: Contact Number:

Type of work: Occupation:

Details

Delete as applicable NON-CONFORMITY/ACCIDENT/NEAR MISS
When did it happen? Date: Local Time: UTC:
Where did it happen?

What PPE was being worn?

Weather conditions at time of event?

Was a Drug/Alcohol test conducted? Who by?

What happened?

What was done? (e.g. medical treatment, inspection cancellation)

How to prevent?

Office use only

Actions to prevent?

Time frame to Close-Out: Proposed date to Close-Out: Actual date of Close-Out:

Name: Signature: Date:

EMERGENCY PROCEDURE NON-CONFORMITY, ACCIDENT OR NEAR MISS REPORT 13